CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:GR
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 725 555.50 20553.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 498 507.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 26 16.25 601.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 655 2023.00 74851.00 37.00
Subtotal (Total Children Is Unduplicated) 1319 3101.75 96005.75 30.95
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 56 54.00 2700.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 61 53.50 2675.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 5.50 412.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 40 34.00 2550.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 10.50 582.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 17.50 1312.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 30.00 2250.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 84 80.50 4467.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 186 161.00 12075.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.00 1850.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 275.00 275.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 19 19.00 921.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 41 41.00 1988.50 48.50
Subtotal (Total Children Is Unduplicated) 446 546.00 35698.00 65.38
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 38.75 1937.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 5.50 275.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 1.00 25.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.75 87.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.75 87.50 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.00 73.42 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 213 1635.00 81750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 73 411.75 27949.59 67.88
PHY-97110-PT SESSION BY LICENSED PT 36 188.00 12761.44 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 77 310.50 21076.74 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 36.00 1955.52 54.32
TRAN-TRAN-FAMILY TRANSPORTATION 387 396.00 3168.00 8.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 777 159430 79715.00 0.50
Subtotal (Total Children Is Unduplicated) 1051 162460 230991.53 1.42
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Total 166107.75 362695.28 2.18
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Number of Children (Unduplicated) With at Least One Service 1614
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 3142 160817.50 228303.87 228089.67
D 87 81.00 2997.00 2997.00
S 0 0.00 0.00 0.00
H 30 1314.50 2798.74 2798.74
T 0 0.00 0.00 0.00
4777 3894.75 128595.67 0.00
Other 0 0.00 0.00 0.00
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Total 8036 166107.75 362695.28 233885.41